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Radiologists highlight adverse events disclosure at RSNA 2011

As RSNA 2011 broadens its focus to see how specialists integrate with fellow health care providers, radiologists take on a greater role in adverse events disclosures.

CHICAGO -- Patient safety and errors disclosure aren't only the purview of doctors at the bedside. As awareness about medical errors and adverse events grows, more specialists must get into the act.

Significantly, that includes radiologists who, as the clinicians first reviewing and interpreting images and tests, are on the front line of medical diagnoses, according to presenters at the Radiological Society of North America's RSNA 2011 annual meeting.

The multifaceted issue of patient safety includes a system in which clinicians feel comfortable disclosing adverse events to patients and families who might be struggling with the emotional impact of a medical error. There is a growing interest in building this system, but what that looks like and how to accomplish it remain obstacles, said Thomas H. Gallagher, M.D., associate professor of medicine at the University of Washington.

"There's a strong sense of commitment to the principle of disclosure," Gallagher said, "but we're really struggling to turn that commitment into practice."

It's especially difficult when that practice includes conversations that can be awkward, emotional and confrontational. The RSNA 2011 presentation, Disclosure of Medical Error in Radiology, also featured an enactment of such a disclosure conversation -- a misread mammogram. A woman discovered a breast tumor had been present in a two-year-old image, but the radiologist had misordered the images he was reading and so concluded the mass was shrinking, not growing. The enactment, which depicted the woman and her husband confronting the radiologist about why the error happened, was based on a true case.

Technology doesn't always make it easier to spot adverse events. In fact, it can be harder on digital workstations to keep an accurate chronology of images, said Joseph Tashjian, M.D., president of St. Paul Radiology in Minnesota. Tashjian participated in the enactment and presentation.

Indeed, the case in the enactment has led St. Paul to consider how software recognizes and identifies the most recent image on a screen, Tashjian told the audience, adding that he would be meeting with vendors to work on developing that software.

Radiologists remain uncomfortable sharing adverse events with patients

There’s a strong sense of commitment to the principle of disclosure, but we’re really struggling to turn that commitment into practice.

Dr. Thomas H. Gallagher, University of Washington

This type of specialty-specific disclosure is still a new avenue in the path to patient safety and accountability. While radiologists say they believe in transparency, how transparent and how truthful they'd be are up in the air.

According to a study conducted by Gallagher and other researchers who explored the issue of the misread mammogram, 51% of radiologists would only disclose an error if they were asked by a patient. As for what they'd disclose, 30% said they would lie about the nature of the tumor growth. Only 15% would be truthful about the images being placed in the wrong order. The research, Disclosing Harmful Mammography Errors to Patients, appeared in a 2009 issue of Radiology magazine.

Radiologists will have to interact more with patients as transparency becomes more important in health care and has a greater impact on quality, Gallagher said. Quality improvement tools are being used to measure how well disclosures are performed, and that data is being gathered and analyzed to create process improvements and better care. "Organizations that are learning have to do more than say 'we're sorry.'"

Let us know what you think about the story; email Jean DerGurahian, Executive Editor.

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